Ottawa County Safety Council
Membership Enrollment Form

Fiscal/Program Year runs from July 1 to June 30 of the given years.

In an effort to reduce the number of workplace accidents and to share resources and information on accident prevention, risk management and workers’ compensation in Ohio, the BWC’s Division of Safety & Hygiene and your local safety council co-sponsor this program. The Ottawa County Improvement Corporation, located at the Ottawa County Community Resource Centre, serves as your local sponsor.

In signing this enrollment form, the employer makes a commitment to send representatives to the majority of safety council meetings and to submit semi-annual reports by the deadline dates.

Annual dues of $120.00* is required upon application. Premium rebates requires full year membership and attendance and training achievements. Requirements for potential rebates provided for reference. Checks payable to: Ottawa County Safety Council

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* 1. Please check if an invoice is required.

Yes

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* 2. Date:

Submited on

Date

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* 3. Membership Information:

Company Name

Full Address

Phone

Fax

Website

Average Number of Employees

Type of Work

BWC Policy Number

Enrollment Year

Name of Member Representative

-Email

Additional Representative Name

-Email

Previous or Other Safety Council Affiliation

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* 4. Membership Application submitted by:

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* 5. By checking this box, I agree to adhere to the information above

Signature

Deadline for Membership Application and dues: June 30, 2016
THANKS FOR YOUR MEMBERSHIP AND THE INVESTMENT IN YOUR WORKPLACE SAFETY!
For questions, please contact Jessica Kowalski: (419) 898-6242 or jkowalski@ocic.biz